Abolition of user fees: the Uganda paradox

Uptake of evidence in policy development: the case of user fees for health care in public health facilities in Uganda

Background

Several countries in Sub Saharan Africa have abolished user fees for health care but the extent to which such a policy decision is guided by evidence needs further exploration. We explored the barriers and facilitating factors to uptake of evidence in the process of user fee abolition in Uganda and how the context and stakeholders involved shaped the uptake of evidence. This study builds on previous work in Uganda that led to the development of a middle range theory (MRT) outlining the main facilitating factors for knowledge translation (KT). Application of the MRT to the case of abolition of user fees contributes to its refining.

Methods

Employing a theory-driven inquiry and case study approach given the need for in-depth investigation, we reviewed documents and conducted interviews with 32 purposefully selected key informants. We assessed whether evidence was available, had or had not been considered in policy development and the reasons why and; assessed how the actors and the context shaped the uptake of evidence.

Results

Symbolic, conceptual and instrumental uses of evidence were manifest. Different actors were influenced by different types of evidence. While technocrats in the ministry of health (MoH) relied on formal research, politicians relied on community complaints. The capacity of the MoH to lead the KT process was weak and the partnerships for KT were informal. The political window and alignment of the evidence with overall government discourse enhanced uptake of evidence. Stakeholders were divided, seemed to be polarized for various reasons and had varying levels of support and influence impacting the uptake of evidence.

Conclusion

Evidence will be taken up in policy development in instances where the MoH leads the KT process, there are partnerships for KT in place, and the overall government policy and the political situation can be expected to play a role. Different actors will be influenced by different types of evidence and their level of support and influence will impact the uptake of evidence. In addition, the extent to which a policy issue is contested and, whether stakeholders share similar opinions and preferences will impact the uptake of evidence.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-014-0639-5) contains supplementary material, which is available to authorized users.

Picking up the bill - improving health-care utilisation in the Democratic Republic of Congo through user fee subsidisation: a before and after study

BACKGROUND

User fees have been shown to constitute a major barrier to the utilisation of health-care, particularly in low-income countries such as the Democratic Republic of Congo (DRC). Importantly, such barriers can lead to the exclusion of vulnerable individuals from health-care. In 2008, a donor-funded primary health-care programme began implementing user fee subsidisation in 20 health zones of the DRC. In this study, we quantified the short and long-term effects of this policy on health-care utilisation.

METHODS

Sixteen health zones were included for analysis. Using routinely collected health-care utilisation data before and after policy implementation, interrupted time series regression was applied to quantify the temporal impact of the user fee policy in the studied health zones. Payment of salary supplements to health-care workers and provision of free drugs - the other components of the programme - were controlled for where possible.

RESULTS

Fourteen (88%) health zones showed an immediate positive effect in health-care utilisation rates (overall median increase of 19%, interquartile range 11 to 43) one month after the policy was introduced, and the effect was significant in seven zones (P <0.05). This initial effect was sustained or increased at 24 months in five health zones but was only significant in one health zone at P <0.05. Utilisation reduced over time in the remaining health zones (overall median increase of 4%, interquartile range -10 to 33). The modelled mean health-care utilisation rate initially increased significantly from 43 consultations/1000 population to 51 consultations/1000 population during the first month following implementation (P <0.01). However, the on-going effect was not significant (P =0.69).

CONCLUSIONS

Our research brings mixed findings on the effectiveness of user fee subsidisation as a strategy to increase the utilisation of services. Future work should focus on feasibility issues associated with the removal or reduction of user fees and how to sustain its effects on utilisation in the longer term.

A qualitative study on barriers to utilisation of institutional delivery services in Moroto and Napak districts, Uganda: implications for programming

BACKGROUND

Skilled attendance at delivery is critical in prevention of maternal deaths. However, many women in low- and middle-income countries still deliver without skilled assistance. This study was carried out to identify perceived barriers to utilisation of institutional delivery in two districts in Karamoja, Uganda.

METHODS

Data were collected through participatory rural appraisal (PRA) with 887 participants (459 women and 428 men) in 20 villages in Moroto and Napak districts. Data were analysed using deductive content analysis. Notes taken during PRA session were edited, triangulated and coded according to recurring issues. Additionally, participants used matrix ranking to express their perceived relative significance of the barriers identified.

RESULTS

The main barriers to utilisation of maternal health services were perceived to be: insecurity, poverty, socio-cultural factors, long distances to health facilities, lack of food at home and at health facilities, lack of supplies, drugs and basic infrastructure at health facilities, poor quality of care at health facilities, lack of participation in planning for health services and the ready availability of traditional birth attendants (TBAs). Factors related to economic and physical inaccessibility and lack of infrastructure, drugs and supplies at health facilities were highly ranked barriers to utilisation of institutional delivery.

CONCLUSION

A comprehensive approach to increasing the utilisation of maternal health care services in Karamoja is needed. This should tackle both demand and supply side barriers using a multi-sectorial approach since the main barriers are outside the scope of the health sector. TBAs are still active in Karamoja and their role and influence on maternal health in this region cannot be ignored. A model for collaboration between skilled health workers and TBAs in order to increase institutional deliveries is needed.

The impact of out-of-pocket payments on health care inequity: the case of national health insurance in South Korea

The global financial crisis of 2008 has led to the reinforcement of patient cost sharing in health care policy. This study aimed to explore the impact of direct out-of pocket payments (OOPs) on health care utilization and the resulting financial burden across income groups under the South Korean National Health Insurance (NHI) program with universal population coverage. We used the fourth Korean National Health and Nutrition Examination Survey (KNHNES-IV) and the Korean Household Income and Expenditure Survey (KHIES) of 2007, 2008 and 2009. The Horizontal Inequity Index (HIwv) and the average unit OOPs were used to measure income-related inequity in the quantitative and qualitative aspects of health care utilization, respectively. For financial burden, the incidence rates of catastrophic health expenditure (CHE) were compared across income groups. For outpatient and hospital visits, there was neither pro-poor or pro-rich inequality. The average unit OOPs of the poorest quintile was approximately 75% and 60% of each counterpart in the richest quintile in the outpatient and inpatient services. For the CHE threshold of 40%, the incidence rates were 5.7%, 1.67%, 0.72%, 0.33% and 0.27% in quintiles I (the poorest quintile), II, III, IV and V, respectively. Substantial OOPs under the NHI are disadvantageous, particularly for the lowest income group in terms of health care quality and financial burden.

Removal of user fees no guarantee of universal health coverage: observations from Burkina Faso

In theory, the removal of user fees puts health services within reach of everyone, including the very poor. When Burkina Faso adopted the DOTS strategy for the control of tuberculosis, the intention was to provide free tuberculosis care. In 2007-2008, interviews were used to collect information from 242 smear-positive patients with pulmonary tuberculosis who were enrolled in the national tuberculosis control programme in six rural districts. The median direct costs associated with tuberculosis were estimated at 101 United States dollars (US$) per patient. These costs represented 23% of the mean annual income of a patient's household. During the course of their care, three quarters of the interviewed patients apparently faced "catastrophic" health expenditure. Inadequacies in the health system and policies appeared to be responsible for nearly half of the direct costs (US$ 45 per patient). Although the households of patients developed coping strategies, these had far-reaching, adverse effects on the quality of lives of the households' members and the socioeconomic stability of the households. Each tuberculosis patient lost a median of 45 days of work as a result of the illness. For a population living on or below the poverty line, every failure in health-care delivery increases the risk of "catastrophic" health expenditure, exacerbates socioeconomic inequalities, and reduces the probability of adequate treatment and cure. In Burkina Faso, a policy of "free" care for tuberculosis patients has not met with complete success. These observations should help define post-2015 global strategies for tuberculosis care, prevention and control.

Healthcare seeking for diarrhoea, malaria and pneumonia among children in four poor rural districts in Sierra Leone in the context of free health care: results of a cross-sectional survey

Background

To plan for a community case management (CCM) program after the implementation of the Free Health Care Initiative (FHCI), we assessed health care seeking for children with diarrhoea, malaria and pneumonia in 4 poor rural districts in Sierra Leone.

Methods

In July 2010 we undertook a cross-sectional household cluster survey and qualitative research. Caregivers of children under five years of age were interviewed about healthcare seeking. We evaluated the association of various factors with not seeking health care by obtaining adjusted odds ratios and 95% confidence limits using a multivariable logistic regression model. Focus groups and in-depth interviews of young mothers, fathers and older caregivers in 12 villages explored household recognition and response to child morbidity.

Results

The response rate was 93% (n=5951). Over 85% of children were brought for care for all conditions. However, 10.8% of those with diarrhoea, 36.5% of those with presumed pneumonia and 41.0% of those with fever did not receive recommended treatment. In the multivariable models, use of traditional treatments was significantly associated with not seeking outside care for all three conditions. Qualitative data showed that traditional treatments were used due to preferences for locally available treatments and barriers to facility care that remain even after FHCI.

Conclusion

We found high healthcare seeking rates soon after the FHCI; however, many children do not receive recommended treatment, and some are given traditional treatment instead of seeking outside care. Facility care needs to be improved and the CCM program should target those few children still not accessing care.

An implementation evaluation of a policy aiming to improve financial access to maternal health care in Djibo district, Burkina Faso

BACKGROUND

To bring down its high maternal mortality ratio, Burkina Faso adopted a national health policy in 2007 that designed to boost the assisted delivery rate and improving quality of emergency obstetrical and neonatal care. The cost of transportation from health centres to district hospitals is paid by the policy. The worst-off are exempted from all fees.

METHODS

The objectives of this paper are to analyze perceptions of this policy by health workers, assess how this health policy was implemented at the district level, identify difficulties faced during implementation, and highlight interactional factors that have an influence on the implementation process. A multiple site case study was conducted at 6 health centres in the district of Djibo in Burkina Faso. The following sources of data were used: 1) district documents (n = 23); 2) key interviews with district health managers (n = 10), health workers (n = 16), traditional birth attendants (n = 7), and community management committees (n = 11); 3) non-participant observations in health centres; 4) focus groups in communities (n = 62); 5) a feedback session on the findings with 20 health staff members.

RESULTS

All the activities were implemented as planned except for completely subsidizing the worst-off, and some activities such as surveys for patients and the quality assurance service team aiming to improve quality of care. District health managers and health workers perceived difficulties in implementing this policy because of the lack of clarity on some topics in the guidelines. Entering the data into an electronic database and the long delay in reimbursing transportation costs were the principal challenges perceived by implementers. Interactional factors such as relations between providers and patients and between health workers and communities were raised. These factors have an influence on the implementation process. Strained relations between the groups involved may reduce the effectiveness of the policy.

CONCLUSIONS

Implementation analysis in the context of improving financial access to health care in African countries is still scarce, especially at the micro level. The strained relations of the providers with patients and the communities may have an influence on the implementation process and on the effects of this health policy. Therefore, power relations between actors of the health system and the community should be taken into consideration. More studies are needed to better understand the influence of power relations on the implementation process in low-income countries.